It is the policy of this
facility to provide equal opportunity to persons regardless of race,
religion,
age, gender, disability or any other classification in accordance with
federal, state and
local
statutes, regulations and
ordinances.

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

If overtime work is required periodically, does this pose a problem for you?

Date Available For Work

Are You Legally Authorized to Work in the U.S.?

Have you ever worked in this or any other facility?

If yes, what facility?

Are you related to another facility employee?

How did you learn about this position?

State Employment Commission

Internet

Agency

Ad

Job Listing

School

Current Employee

Job Line

Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.
Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event: Are you currently excluded from participation in any federally funded
healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health
program?

Educational History

Type of School

Name
of SchoolCity,
State

Check Last YearAttended in School

Degree
or Certificate

High
School

School:
City: State:

9 10 11 12Graduated/GED?

Degree:

College

School:
City: State:

1
2
3
4Graduated?

Degree:

College

School:
City: State:

1
2
3
4Graduated?

Degree:

GraduateSchool

School:
City: State:

1
2
3
4Graduated?

Degree:

Other

School:
City: State:

1 2 3 4Graduated?

Degree:

Other

School:
City: State:

1 2 3 4Graduated?

Degree:

List any professional licenses, registration
or certification you possess
(Include Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applyingTyping (WPM)
PBXProficient in Software: Business machines and/or equipment you can operate: